MEDICARE: FAIRMOUNT PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PP411438L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2086440	OTHER		PK

General Provider Information

NPI Number	:	1073511242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRMOUNT PHARMACY INC

Provider Business Mailing Address
First Line	:	1900 GREEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3207
Country	:	US
Telephone Number	:	215-567-0364
Fax Number	:	215-567-1931

Provider Business Practice Location Address
First Line	:	1900 GREEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3207
Country	:	US
Telephone Number	:	215-567-0364
Fax Number	:	215-567-1931

Authorized Official
Title or Position	:	PHARMACIST MANAGER AND VP
Name	:	GERARD VOLGRAF
Credential	:	RPH
Telephone Number	:	215-567-0364

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	02/23/2015

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Directions to “FAIRMOUNT PHARMACY INC ” Practice Location

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